The PSA test for Prostate Cancer

The Daily Mail on Monday 6th Oct, 2008 discussed the development of an in-house (point of care) device for GPs and Urologists to test their patients and get results at the time of the consultation.

Prostate Specific Antigen (PSA) is becoming more and more frequently measured both by doctors and through kits available online and through high street chemists. Unfortunately PSA is not specific for prostate cancer and levels can rise due to Benign Prostatic Hypertrophy (enlargement associated with age), trauma, recent or frequent sexual intercourse, mild infections and other causes. A one-off rise in PSA measured through a blood test rarely leads to intervention by doctors unless it is particularly high. Repeat tests that are above the normal level for a man’s specific age, or a PSA that is steadily rising over three or four tests, generally leads to recommendation of further investigation.

Traditionally this usually involves an ultrasound done trans-rectally and may lead to an MRI or CT scan but all too frequently leads directly to a biopsy.

Biopsy of the prostate is not a particularly pleasant event and some studies suggest that 80% of biopsies are returned as normal (negative for cancer). Not only has an individual gone through an unpleasant process but a negative test does not necessarily mean there is no cancer as the needle biopsy may have missed the actual tumour.

It has been reported that 38% of prostate cancers are missed by prostate biopsy (Patel, et al. 2004). What is more worrying is the 8 – 11% inaccurate results leading to 105 approximately of men being further treated or investigated incorrectly (Epstein, et al., 2005).

Furthermore, a finding of prostatic cancer, depending on several other factors including the age of the patient, should not necessarily lead to aggressive treatment as autopsy results show that many men will live comfortably with a prostate cancer causing no problems or issues at all.

It is because of all these factors that there is some indecision in the medical world, including urologists and oncologists specialising in this area, as to how best to proceed.

As the Medical Director of The Diagnostic Clinic I am constantly reviewing pioneering techniques in the early detection of cancer as well as trying to pinpoint those who may have a predisposition through genetic or poor immune system function. To that end The Diagnostic Clinic has a specific protocol for patients to follow.

1. A one-off finding of a raised PSA does not require anything other than follow-up. Should results on a monthly re-test indicate a steady rise or a maintained level above the expected range for a gentleman’s age then further investigation is warranted.

2. There is growing evidence that a new test of genetic material known as the PCA3 (prostate cancer gene 3) Assay is going to prove a standard test in the near future. At the moment it costs £360 here at The Diagnostic Clinic and requires the patient to have a prostate massage by a finger passed into the rectum and then a collection of the urine sample immediately. We recommend at the same time a sample of semen/ejaculate to test for infection a cost of about £55.

3. If either PSA or the PCA3 remains high or abnormal then ultrasound is recommended. Trans-rectal prostate ultrasonograpy. This will indicate whether there are any areas within the prostate that have an altered type of texture which can raise suspicions of cancer.

4. If the ultrasound is negative we recommend Magnetic Resonance Imaging (MRI) of the prostate. We try to avoid Computerised Tomography (CT) scanning as this delivers a dose of radiation.

5. A clear ultrasound and MRI would lead us to a watch and wait policy and would not encourage us to recommend biopsy. A repeat of some or any of the above tests should be discussed with one of the doctors here at The Diagnostic Clinic at certain specific times. Some urologists may recommend biopsy and, indeed, if a cancer is noted on the biopsy, treatment decisions can be made more easily. However, as I say above, negative results do not necessarily mean that one is clear of disease and there is also some controversy about potential risks of spread of the prostate cancer through biopsy.

Statistics do not suggest that biopsy of the prostate increases a risk of the spread of cancer but having reviewed the research available I do not think that adequate studies have been performed. Common sense alone would suggest that placing a needle several times into a potentially cancerous area and withdrawing it may carry with it seeds of tumour cells. More importantly, evidence is now coming forward that tumours as small as 2mm could be producing a compound that encourages blood vessel growth. Vascular Endothelial Growth Factor (VEGF) has been shown to be produced by tumours even at such small size. As soon as that is present the risk of spreading cancer into the bloodstream itself increases.

6. If ultrasound or MRI shows a suspicious area then biopsy under ultrasound guidance is recommended. It is important to establish the type and grade of prostate cancer as treatment options vary. A specific grading system known as the Gleason Score governs treatment options.

The Diagnostic Clinic does not have a specific statement about orthodox treatment other than that it recommends full adherence to guidance given by specialists in this area. It is always important, however, to ask the specialist about surgical options, radiotherapy (brachytherapy is the planting of small rods of radiation directly into the prostate or external beam radiation can be utilised) as well as the potential for anti-oestrogen therapies or chemotherapy.

7. Specialised scans looking for “hot spots”, Bone-scans and/or PET scans, are often advised as are other types of scanning. Assessment of the potential spread is extremely important in helping decide treatment options.

Therapeutic Protocols

As mentioned above The Diagnostic Clinic encourages people to follow the advice of their specialist. It is never wise to embark upon Alternative or Complementary medical therapy unless under the guidance of an Integrated Physician (one fully qualified in medicine with post-qualification training or diplomas in Alternative Medicine).

Prostate formulas specifically including plant extracts such as Saw palmetto, Pygeum, Lycopene, antioxidants especially zinc are produced in many forms but The Diagnostic Clinic particularly encourages its patients to use Natural Food State and organic herbal extracts. TDC has its own prostate formula. Higher doses of herbal treatments can be brought into play under supervision.

Gleason scores of 3+3 or below can entertain the use of a Red clover extract known as Trinovin which has been shown in one study (http://cebp.aacrjournals.org/cgi/content/full/11/12/1689 ) to be effective in halting tumour growth and possibly causing recession of prostatic cancer. Decision to use this must be governed by a doctor.

Dr Ben Pfeifer is a Professor of Clinical Research at a private clinic in Switzerland, the Aeskulap Clinic. He is a specialist in cancer immunology with 59 publications. He has derived the Pfeifer Protocol which includes a herbal food supplement for prostatic health, a natural food extract from rice bran and Shitake mushrooms as well as nutritional supplementation in a particular formulation and finally the use of Curcumin which is an established anti-inflammatory and antioxidant compound combined with Resveratrol, another antioxidant, all of which have evidence of efficacy as anti-cancer agents. Early research, still undergoing clinical trials, suggests that this might be a treatment for prostate cancer of all levels and should certainly be considered in those where orthodox treatment is not available or appropriate and also should be considered alongside orthodox treatments.

The cost of Trinovin at therapeutic dosage is around £60 per month whereas that of the Pfeifer Protocol can be as high as £800 initially with a reduction in dosage( and therefore costs) if PSA levels are dropping.

Treatment with Trinovin or the Pfeifer Protocol can be initiated at any of the diagnostic levels mentioned above but, at this time, we recommend stopping treatments 2 weeks prior to any retesting since studies have not been completed on the potential interference of treatments with PSA measurements. In other words we cannot guarantee that the treatments being used will not simply alter the test results without having any actual effect on tumour activity.

I and the doctors at The Diagnostic Clinic would be very happy to clarify any of the areas mentioned above or help you deal with any enquiries about prostate health or prostate cancer.